Download SHAC Dental Operations Manual

Updated January 2011
SHAC Dental Operations Manual
1. Leadership structure.
a. SHAC Dental is completely run by the group of student coordinators. There are
twelve (12) third year dental student coordinators, four to six (4 - 6) second year
dental student coordinators, two (2) second year hygiene coordinators, two (2) first
year hygiene coordinators. Their specific responsibilities regarding the infrastructure
of SHAC Dental and its integration within the larger SHAC unit are listed below.
i. It should be noted that it is the overall responsibility of the dental student
coordinators (and not the hygiene coordinators) for the clinic and all of its
complete workings to be running smoothly and fully operational.
ii. At the beginning of each semester the student coordinators will meet to
decide dates (Tuesday, Wednesday, and Thursday nights) for which the clinic
should be held. There will be no clinic held during school breaks, final
exams, or holidays.
iii. Announcements are made to DDS1, DDS2, and DDS3 students as well as to
Dental Hygiene (DH) and Dental Assisting (DA) students that the SHAC
sign-up sheet for the semester is posted on the student bulletin board.
Students are reminded on the day before their service date via email to show
up for their desired dates and that a coordinator must be notified of an
absence before hand. Students that can not make their assigned service date
will be responsible for finding a replacement for themselves.
iv. There should be either monthly or bi-monthly meetings of the student
coordinators to discuss the overall operation of SHAC Dental and should be
informed via the SHAC Liaison (see Supportive Structure Section) of the
overall workings of SHAC Umbrella organization. These meetings can
include, but are not limited to, the following topics:
1. Clinic management.
2. Community and campus projects.
3. Feedback from previous SHAC participants.
4. Donations and educational tools from numerous departments.
Updated January 2011
5. Goals for the current semester as well as for future coordinators.
6. Ideas from faculty input and suggestions.
7. Financing for materials, asepsis, disinfection, and clinic usage.
v. There should be six DDS3 coordinators and two to three DDS2
coordinators assigned to Tuesday night clinics and Wednesday night clinics.
These groups will stay with their respective day the entire year (Summer, Fall
and Spring) unless there is some arrangement made with the other
coordinators.
2. Clinic Structure:
a. SHAC Dental Clinic will operate on variously designated nights throughout each fall,
spring and summer semester. There will generally be two dental sessions per week in
which patients will receive screenings, extractions, restorative work, and radiographs.
These dental sessions will be held on Tuesday and Wednesday nights and will be run
by the DDS3 and DDS2 coordinators. There will be approximately three hygiene
nights per month in which patients will receive prophylaxis and fluoride treatments.
These nights will generally be held on pre-determined Monday or Thursday nights
during the month. It will be the responsibility of the hygiene coordinators to run
this clinic session. The clinical positions for each night will be described below.
i. Clinical Positions:
1. Per dental session the positions should be filled in the following
way:
The following are to be filled with DDS3 student coordinators
SC1
Surgical coordinator
SC2
Surgical coordinator
TC
Triage coordinator
NC
Screening coordinator
SA1
Surgical Assistant 1 (slot optional)
SA2
Surgical Assistant 2 (slot optional)
The following are to be filled with DDS2 student coordinators
ST1
Sterilization Coordinator 1
ST2
Sterilization Coordinator 2
ST3
Sterilization Coordinator 3 (slot optional)
Updated January 2011
The following are to be filled with volunteers
RO1
restorative operator #1
RO2
restorative operator #2
*Note: RO1 and RO2 are typically DDS3 or
DDS4 students, but also includes DDS2 students
who have successfully completed Dental Materials
and COD)
A1
operator assistant #1
A2
operator assistant #2
A3
operator assistant #3 (slot optional)
*Note: A1, A2, and A3 can be filled by all DDS,
DH and Dental Assisting students
F1
faculty
*Note: Must be UNC SOD Full time or adjunct
faculty or resident (DDS or DMD with NC
license or Instructor’s License)
T1
translator
*Note: Can be any student or outside volunteer
2. Per hygiene session the positions should be filled in the following
way:
The following are to be filled with DH2 & DH1 student
Coordinators
TC1
Triage coordinator #1
TC2
Triage coordinator #2
The following are to be filled with volunteers
H1
hygiene operator #1
H2
hygiene operator #2
H3
hygiene operator #3
H4
hygiene operator #4
*Note: H1-H4 positions are to be filled by hygiene
students on specific hygiene nights
F1
faculty
Updated January 2011
*Note: Must be UNC SOD Full time or adjunct
faculty or resident (DDS or DMD with NC
license or Instructor’s License)
T1
translator
*Note: Can be any student or outside volunteer
3. Descriptions of positions per session:
a.
Surgical Coordinator (SC1 & SC2)  There are two SCs for each
dental session.
i. Responsibilities include screening and assessing patients
for surgical needs; taking needed radiographs; consulting
with faculty prior to and during surgery; performing
extractions; referring appropriate patients to more
advanced care; maintaining accurate patient charts; giving
post-op instructions to patients; properly disinfecting
operatories and preparing space for next patient; verifying
that the operatory is properly shut down at end of session.
b. Triage Coordinator (TC)  There is one TC for each dental
session and two per hygiene session
i. Responsibilities include organizing initial patient admission
protocol (e.g. double lottery – described in paragraph 5);
handing out, collecting and verifying Patient History
forms; triaging patients and setting sequence for
admission; locate existing or create new patient charts;
assign patients to proper SC or RO as needed; keeping
patients informed on when they will be seen; verify that
the door to waiting area is closed and locked at all times;
complete and verify all paperwork regarding procedures
performed and patients seen during session; verify that
each chart is signed by the faculty.
c. Screening Coordinator (NC)  There is one per dental session.
i. Responsibilities include assisting TC in starting patient
flow into clinic; beginning screenings once operatories are
filled with patients; creating new patient charts; performing
extra and intraoral examinations; taking radiographs;
maintaining accurate patient charts; give post-exam
instructions to patient regarding clinic, etc; refer patient to
more advanced care if necessary; properly disinfect
operatory and prepare for next patient; verify that
screening room is shutdown properly at end of session.
d. Surgical Assistant (SA1 and SA2)  there may be zero, one or
two per dental session
i. Responsibilities include assisting SC with all aspects of
their responsibilities as needed.
Updated January 2011
ii. Surgical Assistants have a varied role. The position may go
unfilled if: (a) there are not enough coordinators to staff
the position, (b) There is a missing Restorative Operator,
in which case the Surgical Assistant will fill that role. (e.g. if
O1 is unfilled, SA1 becomes O1, and SA2 will assist SC1 and
SC2).
e. Sterilization Coordinator (ST)  there may be two or three per
dental session.
f.
i. Responsibilities include performing all instrument
sterilization according the sterilization guidelines; fill, run
and empty autoclave; prepare restorative operatories
before each session; provide instrument trays and hand
pieces to SCs and ROs ad needed; collect all instrument
trays and hand pieces from SCs and ROs when finished;
maintain separation of SHAC and Orange County Health
Dept (OCHD) materials; develop radiographs as needed;
help to properly disinfect operatories and prepare for next
patient; verify that all hand pieces are accounted for; verify
that the sterilization area is shutdown properly; verify that
radiograph processing area is shutdown properly.
Restorative Operator (RO)  There will be two per session
i. Responsibilities include screening and assessing patients
for restorative needs; taking needed radiographs;
consulting with faculty before proceeding with procedure;
refering patient out for more difficult cases; maintaining
accurate patient charts; giving post-op instructions to
patient; submit patient chart to Triage coordinator;
properly disinfecting operatory; prepare operatory for next
patient.
ii. Generally the ROs perform one restorative procedure
per patient unless some exception is noted.
g. Operator Assistant (A)  There will be zero, one, two or three
per session
i. These volunteers assist ROs in their efforts to restore
patients’ dentition. They are allowed to fulfill the normal
dental assisting roles.
h. Hygiene Operators (H1 and H2)  There will be four per
hygiene session
i. Their responsibilities include obtaining needed
radiographs; consulting with faculty before proceeding
with procedure; referring pt if necessary; maintaining
accurate pt charts; giving post-op instructions to pt;
submitting pt chart to Triage coordinator; properly
disinfecting operatory and preparing for next patient.
ii. On hygiene nights these individuals should be prepared to
help in returning the clinic to its normal operating state.
They should remove UNC SOD cavitrons if necessary and
take all instruments to sterilization area.
Updated January 2011
i.
Translator (T)  There may be zero or one for each session
i. The initial role of the Translator will be to aid the TC and
NC during the PAP with Translation of EnglishSpanish.
Afterwards, the T will freely move throughout the clinic
helping on an as-needed basis.
ii. Note: that Translators are volunteers and may leave at any
time, so it is important that each session team have some
capability within itself to be able to communicate with the
patient pool.
4. Operation of each clinic session
a.
b.
c.
d.
e.
f.
g.
h.
Student Coordinators should arrive at the clinic no later than 5:30
in order to prepare operatories and all forms needed for the clinic
(see forms section below). Any new patient charts that would be
needed should be created before the patients and volunteers arrive.
It is the responsibility of the TC and NC to direct volunteers in
their various positions and inform them of the rules and
regulations of SHAC Dental. Each RO should be assigned an
operatory and an assistant.
Gowns should be handed out to all individuals providing pt care.
Start up and Shut down procedures of each respective section of
the clinic are listed in the section below.
New pts will be required to fill out a health history form prior to
being seeing by NC.
All health history forms should be reviewed with each patient
before receiving any treatment. Also, all operators should obtain
vitals prior to starting any procedure.
Pts will be assigned to each operator/surgical coordinator
depending on their need and position in the lottery (see next
section).
Patients will begin being treated at 6:00pm and should be finished
with treatment by 9:00pm. Any patients that will likely not be seen
due to time constraints should be informed no later than 8:00pm.
5. Start Up and Shut Down Procedures
a. Clinic Start Up
i. Keep doors locked at all times. Turn on all lights.
ii. Start up each operatory, x-ray processor, suction and feed
switches, x-ray machine (see below for specific
instructions).
iii. Empty Autoclave and put away all items. Load and start
Autoclave if there is a need to do so.
iv. Place sterile handpieces in Sterilization Center.
b. Clinic Shut Down
i. Place all used green towels in hamper and gather all gowns
for return to UNC SOD.
ii. Collect and verify number of handpieces and any other
instruments borrowed from UNC SOD. Give to person
in charge of returning instruments to SOD.
iii. Make inventory check for items needed for following
week.
Updated January 2011
c.
d.
e.
f.
g.
h.
iv. Make sure all paperwork is filed and all patient charts are
returned to proper place. Make sure that necessary
paperwork is turned into OCHD.
v. Shut down x-ray area, all operatories, x-ray processor,
suction and feed switches, and sterilization area.
vi. Check to make sure all doors are locked. Turn off lights.
Everyone should exit together through rear exit.
Operatory Start Up
i. Replace plastic and tips as needed
ii. Fill water bottle, run water for 30 seconds for each syringe.
iii. Place proper cart into operatory from storage and verify
that cart has appropriate amount of supplies.
iv. Setup Amalgamator and Curing Light
v. Place a kit and hand pieces (do not open!)
Operatory Shut Down
i. Disinfect operatory and replace plastic and tips as needed
ii. Empty water bottle
iii. Run hot water through all suction lines for 60 seconds
iv. Make sure that cart is organized and place all materials
back into cart. Run through supply checklists. Return
Cart to storage.
Start up of X-ray Processing Area
i. Place cover onto Processor and turn processor on.
ii. Ensure that there are rubber gloves, paper towels and
disinfectant in the area.
Shut down of X-ray Processing Area
i. Turn off Processor
ii. Dislodge cover from processor
Sterilization Start Up
i. Add distilled water to Autoclave if necessary
ii. Empty Autoclave if needed and refill and start if needed.
Sterilization Shut Down
i. Fill and start Autoclave if needed
ii. Make sure counters are clear and cleaned.
iii. Make sure Ultrasonic is clean and empty and replace lid.
6. Lottery System
a. SHAC Dental is operated on a lottery system in which the patients
3. Protocol
a. Paperwork
that are awaiting treatment are divided into two groups: returning
patients and new patients. Within each group, each patient is
randomly assigned a number and patients are then seen based on
their position according to the number drawn.
b. SHAC Dental is NOT operated on a first come, first serve basis.
However, if it is decided that a patient has a very urgent need
regardless of their number in the lottery then the patient can be
seen as soon as it is deemed possible. This completely at the
discretion of the TC and NC.
Updated January 2011
i. Each night there are three types of paperwork that must be completed before
the end of each clinic session. They include Patient Chart entries, Patient
List and Patient Procedure Tally. Descriptions of these are listed below:
1. Patient Chart entries include any new health history forms, entry of
any screening performed and any observations noted, as well as all
progress note entries that must be made for each patient after
treatment is rendered. Progress notes must be signed by both the
person performing the treatment and the faculty member. These are
all to remain in the patient chart and the chart must be returned to
the file cabinet at the end of each clinic session.
2. Patient Lists are generated by the TC and NC at the beginning of
each clinic session and include the patient’s name and need and
lottery number. There will be a list for new patients and a separate
list for returning patients. These lists will be used by the TC to
determine which patients should be seen when and which operator
should see the patient. At the end of each clinic session these lists
should be placed in the appropriate file in the forms file cabinet.
3. Patient Procedure Tally is a table that should be filled out by the TC
at the end of each clinic session that describes each patient and the
treatment that they received. This form should be copied and the
copy should be placed in the slot on the OCHD door (for their
record keeping purposes). The original form should be placed in the
appropriate file in the SHAC forms file cabinet.
b. Sharp Stick Protocol
i. There is a specific protocol that should be followed very closely if a stick
were to occur. The protocol has been determined by UNC SOD and it is
imperative that each coordinator be prepared to deal with this situation
should it arise. These forms with all of the needed information can be found
in the forms file cabinet.
ii. There should be at least three coordinators for each night trained by the
Orange County EMS to be able to draw blood from patients. If a stick
Updated January 2011
occurs the coordinator should draw blood using the appropriate supplies
(located in the bottom drawer of the forms file cabinet) from both the source
patient and the stuck individual. The protocol established on the Sharps
Stick Sheet should be followed and all appropriate forms filled out. These
should be all collected and the samples transported to the UNC Hospital
Blood Lab for testing.
iii. Linda Stewart at the UNC SOD should be informed of the incident
immediately so that proper follow-up by the school can occur.
4. Supportive Structure
a. In order for SHAC Dental to completely operate and run and smoothly as possible
there needs to be many other positions beyond the clinical responsibilities that must
be filled. These positions are listed below and are to be filled by any dental student
coordinator (DDS2 or DDS3) except for Student and Faculty Recruiter (must have
one of each for hygiene and dental and the hygiene positions should be DH1 or
DH2 student coordinator).
i. Gown/Hand Piece Pick-up (2 coordinators)  There MUST be one per session
1. Responsible for retrieving all items from the UNC-DS sterilization area for
use during the session on the same day; verifies that the items retrieved are
the correct type and quantity for the session; returns all items retrieved the
day after the session
ii. Shut-down Sergeant (2 coordinators)  There MUST be one per session
1. Responsible for verifying that the overall OCHD clinic is clean, shutdown
properly, vacant, and locked after each session. This includes:
a. Verifying that the restorative operatories are shutdown properly
b. Verify that the general clinic areas are cleaned properly
c. Verify that the office is properly locked at the end of session
iii. Faculty Recruiter (1 per dental clinic and hygiene clinic)
1. Recruits faculty for each session night
2. Acts as point of contact for faculty if they need to cancel or change their
availability; Sends reminder notifications to faculty at appropriate times;
Keeps SHAC Teams updated with Faculty information.
3. Note: all coordinators should be recruiting for new faculty at all timeshowever, the Faculty Recruiter must formally make the arrangements.
iv. Student Recruiter (1 per dental clinic and hygiene clinic)
1. Recruits students to act as volunteers for SHAC sessions; Posts sign-up
sheet for students; Keeps student body informed of volunteer
opportunities; Sends reminder notifications to volunteers at appropriate
times; enforces volunteer guidelines as needed; Solicits additional volunteers
Updated January 2011
if signup sheet is not full; Proposes SHAC dates for each upcoming
semester; informs volunteers of any changes to the schedule.
v. OCHD Liasion  MUST be DDS3 Wednesday night coordinator
1. Acts as point of contact to the OCHD team for all issues; sends weekly
status reports to head of OCHD; submits material requests to OCHD on
weekly basis; verifies functionality of OCHD provided medical emergency
kit on a weekly basis;
vi. Materials Liasion  in charge of getting dental materials from outside sources
1. Explore all methods and means of acquiring materials from sources as: sales
reps, dental supply companies; UNC-DS; dentists; family and friends of
anyone. The Material Liaison does necessarily need to be the one to make
contact with the source, but will monitor the progress, and notify the
SHAC teams of any new materials that are received.
2. Note: all coordinators should stay aware of any opportunities that arise to
acquire materials for use in the clinic
vii. Inventory Control (2 coordinators)  MUST be one coordinator per session
1. Restock the restorative carts at the end of each session; Runs through
OCHD provided materials checklist at end of each session, and submits
checklist to OCHD Liaison; Runs through SHAC materials checklist at end
of each session, and submits checklist to Materials Liaison.
2. Note: some dental materials are supplied to SHAC from OCHD. Those
materials that are not to be acquired elsewhere.
viii. SHAC Liasion
1. Keeps in contact with the Medical SHAC, explores opportunities with
Medical SHAC, including funding, public assistance, and health-oriented
opportunities. Also looks for opportunities to promote SHAC at other
similar functions.
2. This individual acts as the SHAC Dental representative on the SHAC CC
board and must attend monthly meetings on behalf of SHAC Dental at
these and other SHAC Umbrella events.
ix. UNC Organization / Visitor Liasion
1. Keeps in contact various UNC SOD organizations such as (but not limited
to) Spurgeon, HDA, UNC PreDental Society, ENNEAD, and individuals
who wish to visit SHAC during a session; Receive and limit requests to visit
and observe during sessions. Examples: The HDA is considering providing
an interpreter for some sessions; the PreDental Society has in the past sent
small groups of students to SHAC to observe what dentistry is about.
x. Hygiene and Prevention Liasion  MUST be a DDS3 Tuesday night
coordinator
1. Monitor the current Hygiene & Prevention efforts at SHAC; Suggest
methods to improve the program; Manage implementation of the changes;
Coordinate changes with other SHAC members; Interface with Dental
Hygiene and Assisting Programs for the advancement of such programs;
Act as POC for all Hygiene and Prevention based issues.
xi. Treasurer
1. Not needed at this time  once money is available this may be of some
concern.
Updated January 2011
5. Volunteer tracking
a. There are no forms that need to be signed by volunteers prior to treating patients at
SHAC Dental. The UNC SOD’s insurance covers any UNC SOD student or faculty
that participates at SHAC.
i. However, it is important to note that outside volunteers (not affiliated
with UNC SOD) are NOT allowed to participate in the treatment of
patients and are only allowed to observe procedures. They should not
aid in clean-up of the operatories as well.
b. Tracking  Volunteers’ Names, PID and affiliation with SHAC Dental (i.e. UNC
SOD class or Pre-Dental organization) are recorded for each clinic session. This
information is compiled at the end of each month and turned into SHAC for various
purposes. This information will be entered into to the appropriate electronic
tracking system used by SHAC and should be the responsibility of the SHAC
Liasion.
c. It is generally assumed that each volunteer is present at the clinic for 3.5 hours (due
to the hours of operation of the actual clinic).
6. The Transition
a. New coordinators for the upcoming year are selected very early in the Spring
Semester (by beginning of February). These individuals should be selected from the
DDS1 and DDS2 class for each particular position previously described.
b. The new applicants for coordinators are evaluated based on their application (essays,
etc) and their ability to perform good patient care.
c. Each new coordinator will be required to read the SHAC Dental Operations manual
prior to observing at the clinic. There will be both an electronic and hard copy of
the Operations Manual that should be passed from each SHAC Liaison and should
be updated as necessary. It is the responsibility of the SHAC Liaison to update this
each year. There should also be a hardcopy of the manual in the forms file cabinet at
the clinic.
d. Orientation/Training
i. New Coordinators will be required to observe for at least three clinic sessions
prior to starting their position as coordinator. These observations will occur
Updated January 2011
during the Spring Semester and each new coordinator should work to
familiarize themselves with all of the protocols and procedures associated
with SHAC Dental.
ii. There should be a rotation set for the incoming coordinators so that there is
not overcrowding at SHAC. Each new coordinator should sign up for at
least three shadowing slots and should be prepared to stay the entire length
of the clinic session.
iii. New coordinators should work to familiarize themselves with each
coordinator position (probably working one-on-one with a particular
position each night). Should any questions arise, it is imperative that they ask
current coordinators and all issues be resolved.
iv. Following the shadowing rotation of new coordinators a meeting should be
held between the new coordinators and current coordinators so that any and
all questions can be answered as well as Support Positions assigned. The
new coordinators should learn their new support position from their
coordinator mentor (person previously in that support position).
7. Contact information
a. Faculty Advisor: Dr. Allen Samuelson
i. Phone: 919-966-6917
ii. Email: [email protected]
iii. Location: 0017 Tarrson Hall (Geriatrics Dept)
b. Organizations:
i. UNC’s Pre-Dental Honor Society - Delta Delta Sigma
c. 2011-2012 SHAC Dental Coordinators:
i. DDS3
Andy Ciesielski
Erica Findley
Rob Fromuth
Natalie Jackson
Sarah Lee
Holly Parsons
ii. DDS2
Elizabeth Consky
Sonam Shah
Bryan Whitecotton
Melissa Smith
Jason Strein
Travis Whitley
Sara Valencia
Magi Youssef
Leslie Yuan
Updated January 2011
8. Tips about common problems.
a. Often patients come to Dental SHAC claiming that they have been previously seen
and have medical histories already filled out but a chart can not be located. To deal
with this situation, the TC should make sure that all possible names that have been
used should be checked for a chart. If a chart is not found, simply create a new chart
and a new screening will need to be performed.
9. Documents
a. All documents that are needed are found in the Forms File Cabinet. Also, all forms
are included at the end of this document.
10. Liability issues.
a. The UNC SOD has liability insurance to protect all of its students, residents and
faculty. Since this is a clinic supported by the school the liability insurance acts as an
umbrella policy at SHAC Dental. However, since all individuals not associated
with the school are not covered by the insurance, they are not allowed to be involved
with direct patient care or instrument handling.
Updated January 2011
SHAC Dental Clinic
Consent to Surgical / Invasive Procedure(s)
I, ____________________________________, certify that the recommended surgical procedure
(Patient’s Name)
has been carefully explained to me.
The treatment is ____________________________________________________.
(Surgery & Tooth number)
The procedure will be completed by _________________________________________.
(Surgeon’s Name)
I have been informed of the benefits of and alternatives to the procedure. I understand that the risks
that may occur as a result of this procedure are, but are not limited to:
1. Bleeding, swelling, infection
2. Temporary numb lip and/or tongue
3. Dry socket, post-op pain or discomfort
4. Maxillary sinus exposure
5. Reaction to local anesthetic
6. Post-op trauma (chewed lip/tongue)
7. Damage to adjacent/other teeth
8. Nerve damage
All my questions have been answered to my satisfaction.
Signature of Patient:________________________________________________
Date: ________________________
SHAC USE ONLY
Signature of Person Performing Procedure:_____________________________________
Date: _________________
Signature of Supervising Dentist: ____________________________________________
Date: _________________
Updated January 2011
SHAC
Dental Clinic
Name(Last)_____________________________
(First) _________________
Date of Birth:____________________
Phone: ______________________
Address: _________________________________________________________
__________________________________________________________
Directions for the Patient: The following information about your health history is very important to provide you
with safe dental care. Incorrect information may be dangerous to your health. Please ANSWER ALL QUESTIONS
by circling the response most appropriate for you.
Name of your Physician or Place you receive medical care: _____________________________
Physician’s Phone: ________________ Address:______________________________________
1. Are you in good health? .................................................................................................... Yes No Don’t Know
2. Has there been any change in your health during the last year? ....................................... Yes No Don’t Know
3. Are you currently under the care of a physician for any condition? ................................. Yes No Don’t Know
If yes, explain ___________________________________________________________________________
4. Are you currently taking any medications of any kind? ................................................... Yes No Don’t Know
If yes, list medication(s), dosage, and reason for taking. _________________________________________
_______________________________________________________________________________________
5. Do you need to have antibiotic premedication before dental treatment? .......................... Yes No Don’t Know
6. Have you ever had any allergic or unusual reactions to dental anesthetic? ..................... Yes No Don’t Know
7. Have you ever had excessive bleeding during dental treatment? ..................................... Yes No Don’t Know
8. Have you ever had or been treated by a physician for any of the following conditions:
a) Allergies, especially to medications ....................................................................... Yes No Don’t Know
b) Asthma ................................................................................................................... Yes No Don’t Know
c) Abnormal bleeding ................................................................................................. Yes No Don’t Know
d) Blood transfusion ................................................................................................... Yes No Don’t Know
e) High Blood Pressure ............................................................................................... Yes No Don’t Know
f) Rheumatic Fever ..................................................................................................... Yes No Don’t Know
g) Heart disease or heart valve problems .................................................................... Yes No Don’t Know
h) Hepatitis ................................................................................................................. Yes No Don’t Know
i) Epilepsy or seizures ................................................................................................. Yes No Don’t Know
j) Diabetes ................................................................................................................... Yes No Don’t Know
k) Sexually transmitted diseases ................................................................................. Yes No Don’t Know
l) AIDS, AIDS-related condition, or HIV positive ..................................................... Yes No Don’t Know
m) Psychological or mental problems......................................................................... Yes No Don’t Know
9. Women – are you pregnant now? ..................................................................................... Yes No Don’t Know
10 Explain any other condition or problem the dentist should know in order to provide you with safe dental care.
_________________________________________________________________________________________
_________________________________________________________________________________________
SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of
my knowledge the answers I have given are accurate.
PERSON COMPLETING THIS FORM:
Signature: ______________________________________________________Date:___________________
If other than patient, indicate relationship:_____________________________________________________
EXAMINING DENTIST’S COMMENTS AND SUMMARY OF SIGNIFICANT FINDINGS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Updated January 2011
SHAC
Clínica Dental
Apellido_____________________________ Nombre _____________________
Fecha de Nacimiento__________________ Teléfono _____________________
Dirección _______________________________________________________
__________________________________________________________
Instrucciones para los pacientes: La siguiente información sobre su historial médico es muy importante para
proveerle de un mejor cuidado dental. Información incorrecta puede ser peligrosa para su salud. Por favor,
RESPONDA A LAS PREGUNTAS haciendo un circulo en la respuesta que usted considere más apropiada.
Nombre de su médico o lugar donde usted recibe cuidado médico: _____________________________
Número de teléfono de su médico: ________________
Dirección de su médico:______________________________________
1. ¿Está en Buena salud? ..........................................................................................................................Si
No
No se
2. ¿Ha habido algún cambio en su salud en los 2 últimos años? ......................................................Si
No
No se
3. ¿Está bajo el cuidado de algún médico actualmente? .....................................................................Si
No
No se
Si la respuesta es sí, explique_____________________________________________________________________
4. ¿Está tomando algún medicamento de algún tipo, actualmente? .................................................Si
No
No se
Si la respuesta es sí, liste las medicinas, la cantidad (dosis) y las razones por las que las está tomando.
_____________________________________________________________________________________
5. ¿Necesita antibióticos antes de cualquier tratamiento dental? ......................................................Si
No
No se
6. ¿Ha tenido alguna alergia o alguna reacción inusual a la anestesia dental? .................................Si
No
No se
7. ¿Ha tenido alguna vez sangrado excesivo durante algún tratamiento dental? ............................Si
No
No se
8. ¿Ha sido tratado alguna vez por su médico de las siguientes condiciones?
a) Alergias especiales a medicamentos .......................................................................................Si
No
No se
b) Asma ...........................................................................................................................................Si
No
No se
c) Sangrado anormal (excesivo) ...................................................................................................Si
No
No se
d) Transfusión sanguínea..............................................................................................................Si
No
No se
e) Presión arterial alta ....................................................................................................................Si
No
No se
f) Fiebre reumática.........................................................................................................................Si
No
No se
g) Enfermedad del Corazón, o problemas con las válvulas del corazón .............................Si
No
No se
h) Hepatitis......................................................................................................................................Si
No
No se
i) Ataques epilépticos ....................................................................................................................Si
No
No se
j) Diabetes .......................................................................................................................................Si
No
No se
k) Enfermedades de transmisión sexual ....................................................................................Si
No
No se
l) SIDA, enfermedades relacionadas con SIDA, o HIV positivo .........................................Si
No
No se
m) Problemas psicológicos o mentales ......................................................................................Si
No
No se
9. Mujeres– ¿está embarazada actualmente? .........................................................................................Si
No
No se
10 Explique alguna otra condición o problema que el dentista deba saber para proveerle de un mejor cuidado dental.
_________________________________________________________________________________________
_________________________________________________________________________________________
FIRMA DEL PACIENTE: Entiendo la necesidad de contestar estas preguntas correctamente y con la verdad. En el
mejor de mis conocimientos, las respuestas que he contestado son correctas.
PERSONA QUE COMPLETA ESTE FORMULARIO:
Firma: ______________________________________________________Fecha:___________________
Si diferente del paciente, indique la relación:___________________________________________________
COMENTARIOS DEL DENTISTA QUE LO EXAMINO Y RESUMEN DE ENCUENTROS
SIGNIFICATIVOS:
________________________________________________________________________________________
________________________________________________________________________________________
Updated January 2011
SHAC Dental Clinic
Patient Record
Date:_______________ Name(last,first):____________________________________________
Chief Complaint:
_____________________________________________________________________
______________________________________________________________________________
Mark each line below: (/) = Normal or Absent, (X) = Abnormal or Present, No mark – Not examined
Extraoral Exam:
Head ____
Neck ____
Skin ____
Intraoral Exam:
Lips ____
Mucosa ____
Vestibules ____ Oropharynx ____ Hard/Soft Palate ____
Tonsils ____
Tongue ____
FOM ____
Gingiva ____
Mobility ____
Pocket Depth ____
Type II
Type III
Periodontium:
Perio Classification: Type I
TMJ ____
Gingiva ____
Type IV
Profile ____
Salivary Glands ____
Type V
Comments:
___________________________________________________________________________
___________________________________________________________________________
Clinical Exam & Radiographic Analysis of Dentition (Caries, Defective Restorations, Fractures, etc.)
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Finding
C/R
#
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Finding
Treatment Summary (After Tx of above item, make entry below. Start new Pat. Rec. when 1-8 is full)
#
Treatment Item
Date Completed
Initials
1
2
3
4
5
6
C/R
Updated January 2011
7
8
8
9
10
Examiner's Signature & Student #: ______________________________________________________
Updated January 2011
POST-OPERATIVE INSTRUCTIONS






Bite on gauze until active bleeding has stopped
Avoid very hot and cold drinks for the rest of the day
Do not rinse the mouth or spit for the rest of the day
Do not use a straw or smoke!
Be careful not to bite your check, lips, or tongue – they are still numb
You may take Children’s Tylenol for pain (if you are not allergic to Tylenol)
Parents: Soft tissues near the extraction may be numb for as long as 2 ½ hours. During this time,
your child may bite or chew on their lip, cheek, or tongue. As a parent, please observe your child,
and stop them from doing this to avoid injury.
Indicaciones post-operatorias:

Mantenga la gasa en el sitio de la extracción con presión firme por 20 minutos y
cámbiela, hasta que pare el sangrado.

No se enjuague la boca ni escupa el resto del día. Si tiene que escupir, solo deje que
salga la baba sóla, sin hacer esfuerzo.

No tome líquidos ni muy calientes ni fríos.

No use popote/pajilla/pitillo o bombilla.

No se muerda los labios, las mejillas, ni la lengua mientras estén adormecidos

Puede tomar Tylenol para niños (si no tiene alergia al medicamento.)
***Padres: Algunos tejidos cerca del sitio de la extracción pueden estar adormecidos por dos horas y
media. Durante este tiempo, es posible que, debido al adormecimiento, los niños se muerdan o
masquen el labio, la mejilla, o la lengua. Como padre, debe observar a su hijo muy cuidadosamente
para evitar que se lastime.
Updated January 2011
SHAC Dental Clinic
Name (last, first):___________________________________
Progress Notes
Date
Tooth #
Description (followed by Name, Signature & Student #, then Faculty Signature)
Updatebottom of Patient Record Form after completing Note
Updated January 2011
SHAC Dental Clinic
Patient List
Day: _____ Date:_________________
Patient Name
SHAC
Patient
(Y/N)
Lottery
#
Triage Coordinator:__________________________
Procedure
(ext, filling, clean)
Pain
(Y/N
)
Notes
(dismissed)